Karin M. Henriksson

All-cause mortality in 272,186 patients hospitalized with incident atrial fibrillation 1995-2008: a Swedish nationwide long-term case-control study.

Aims To evaluate long-term all-cause risk of mortality in women and men hospitalized for the first time with atrial fibrillation (AF) compared with matched controls. Methods and results A total of 272 186 patients (44% women) ≤85 years at the time of hospitalization with incidental AF 1995–2008 and 544 344 matched controls free of in-hospital diagnosis of AF were identified. Patients were followed via record linkage of the Swedish National Patient Registry and the Cause of Death Registry. Using Cox regression models, the long-term relative all-cause mortality risk, adjusted for concomitant diseases, in women vs. controls was 2.15, 1.72, and 1.44 (P < 0.001) in the age categories ≤65, 65–74, and 75–85 years, respectively. The corresponding figures for men were 1.76, 1.36, and 1.24 (P < 0.001). Among concomitant diseases, neoplasm, chronic renal failure, and chronic obstructive pulmonary disease contributed most to the increased all-cause mortality vs. controls. In patients with AF as the primary diagnosis, the relative risk of mortality was 1.63, 1.46, and 1.28 (P < 0.001) in women and 1.45, 1.17, and 1.10 (P < 0.001) in men. Conclusion Atrial fibrillation was an independent risk factor of all-cause mortality in patients with incident AF. The concomitant diseases that contributed most were found outside the thromboembolic risk scores. The highest relative risk of mortality was seen in women and in the youngest patients compared with controls, and the differences between genders in each age category were statistically significant.

Survival after stroke — The impact of CHADS2 score and atrial fibrillation

OBJECTIVE This study examined all-cause mortality in stroke patients with and without documented atrial fibrillation (AF), and the impact of CHADS(2) score. DESIGN A cohort of 105,074 patients, 31,821 (30.3%) with and 73,253 (69.7%) without documented AF, was studied. These patients were registered in the Swedish Stroke Registry during the years 2001-2005. Mortality data were retrieved from the Swedish Cause of Death Register. CHADS(2) score prior to stroke were assessed using the Swedish National Discharge Register. RESULTS The age and sex adjusted relative risk (RR) of death was 1.46 (1.43-1.49) for AF vs non-AF patients. High age (>or=75 years) tripled the risk of death and was the single most important predictor, followed by congestive heart failure, previous stroke and diabetes. Less than half of the AF patients with a CHADS(2) score of 1-6 survived more than 5 years, whereas AF patients with a CHADS(2) score of 0 had a 73% chance of survival. In patients with AF, the relative risk of death was 6.05 (CI: 2.26-6.95); in subjects with the highest vs the lowest CHADS(2) score; the corresponding RR for non-AF patients was 7.93 (CI: 7.01-8.97). CONCLUSIONS The CHADS(2) score seems to have an impact on all-cause mortality after stroke. The CHADS(2) score can give valuable insight for other outcome variables apart from having had an ischemic stroke and can be applied to patients with different risk factor profiles, e.g. with a previous known cardiovascular disease but without known AF.

Ischemic Stroke and Secondary Prevention in Clinical Practice A Cohort Study of 14 529 Patients in the Swedish Stroke Register

Background and Purpose— Secondary prevention is recommended after stroke, but adherence to guidelines is unknown. We studied the prescription of antiplatelet drugs, angiotensin-converting enzyme inhibitors, statins, and anticoagulant drugs and their relation to risk of death. Methods— Patients with first-ever ischemic stroke in 2005 were registered in the Swedish Stroke Register. Odds ratios, hazard ratios, and 95% CIs were calculated using logistic and Cox proportional hazard regression models. Adjustments were performed for age, sex, cardiovascular risk factors, other drug therapies, and activities of daily living function. Results— In total, 14 529 patients with a mean age of 75.0 (±11.6) years were included. They were followed for 1.4 (±0.5) years: 52% had hypertension, 26% atrial fibrillation, 19% diabetes, and 15% were smokers. The odds ratio for prescription of antiplatelet was 2.20 (95% CI, 1.86 to 2.60) among the oldest patients (≥85 years of age) compared with the youngest (18 to 64 years of age). The corresponding odds ratio was 0.38 (0.32 to 0.45) for prescriptions of angiotensin-converting enzyme inhibitors, 0.09 (0.08 to 0.11) for statins, and 0.07 (0.05 to 0.09) for anticoagulant therapy. Prescription of statin and anticoagulant therapy was associated with reduced risk of death (hazard ratio, 0.78 [0.65 to 0.91] and hazard ratio, 0.58 [0.44 to 0.76], respectively) but not the prescription of antiplatelet drugs or angiotensin-converting enzyme inhibitors. Conclusions— The prescription of antiplatelet, angiotensin-converting enzyme inhibitors, statins, and anticoagulant therapy was strongly age related. Statin and anticoagulant therapy was associated with reduced risk of death and seemed to be underused among elderly patients. These findings should encourage physicians to follow todays guidelines for stroke care.

Health and development in the first 4 years of life in offspring of women with schizophrenia and affective psychoses: Well-Baby Clinic information

The investigation of genetic high-risk (HR) groups provides the opportunity to study diathesis characteristics associated with schizophrenia (Sc) and affective psychoses. High-risk offspring of women with a history of schizophrenia, affective and other psychoses (n = 84), as well as normal-risk control (NC) offspring (n = 100), were studied from 0 to 4 years of age, using prospectively recorded information from Well-Baby Clinic (WBC) records. Blind assessment of an average of 25 contacts per subject yielded data concerning early life developmental, physical and behavioral characteristics associated with psychosis risk. As compared with controls, offspring of women with schizophrenia showed significantly increased rates of delayed walking, visual dysfunction, language skill disorders, enuresis, disturbed behavior (especially poor social competence), and multiple accumulated risk characteristics. Significant Sc-risk characteristics did not include impaired hearing, minor malformations, biological dysfunctions, or physical illness leading to treatment. Offspring of mothers with affective psychosis (Aff) showed only a significantly increased rate of delayed walking, with no significantly increased total aggregation of risk characteristics, compared with controls. The results suggest a limited overlap in the diathesis characteristics associated with risk for Sc vs. Aff psychosis. The importance of these early risk characteristics for the later development of psychopathology is being investigated in this sample.

Associations between body height, body composition and cholesterol levels in middle-aged men. the coronary risk factor study in southern Sweden (CRISS)

Background: Short body height is associated with increased risk for coronary heart disease; however, mechanisms are not fully explained. In this study, associations between body height and serum cholesterol, non-high-density lipoprotein (non-HDL cholesterol) and high-density lipoprotein (HDL cholesterol) were investigated. Methods: Prospective cohort study of middle-aged men from Helsingborg, Sweden starting 1990. Two birth-year cohorts were invited at 37, 40 and 43 years of age; participation at baseline was 991 (68%). Serum and HDL cholesterol, systolic and diastolic blood pressure, weight, height, waist and hip circumferences were measured. Non-HDL cholesterol, body mass index (BMI) and waist/hip ratio (WHR) were calculated. The participants completed a questionnaire covering lifestyle variables. Results: There were statistically significant inverse correlations between body height and serum cholesterol (−0.11) and non-HDL cholesterol (−0.12). One standard deviation, 6.7 cm, taller body height was associated with a lower serum cholesterol (−0.12 mmol/l) and a lower non-HDL cholesterol (−0.13 mmol/l; p < 0.001). These associations remained when adjusted for BMI and WHR. Men with serum cholesterol equal to or above 6.5 mmol/l were significantly shorter (mean 178.71 cm) than men with serum cholesterol below 6.5 mmol/l (mean 179.71 cm). In addition, BMI and WHR were positively associated with serum and non-HDL cholesterol and inversely associated with HDL cholesterol. The change in cholesterol levels over the six-year follow-up was significantly associated to the change in BMI and WHR. Conclusions: Body height had an independent and inverse relation to serum cholesterol and non-HDL cholesterol in middle-aged men, and the lipid pattern suggests that the underlying mechanism might be different from the traditional association between lipids and the metabolic syndrome. Although the direct clinical implication is limited, our results may help to explain the association between short height and risk of myocardial infarction.

A prospective study of offspring of women with psychosis: visual dysfunction in early childhood predicts schizophrenia-spectrum disorders in adulthood

Objective:  Children with visual dysfunction have perinatal, neurological, visual‐perceptual and cognitive abnormalities, similar to schizophrenia patients. We prospectively investigated whether visual dysfunction in childhood selectively predicts adult schizophrenia‐spectrum disorders, and is related to childhood neurological abnormality.

Incidence, mortality rates and causes of deaths in haemophilia patients in Sweden.

Sweden has been a pioneer in the treatment of haemophilia, with the first concentrate available in the 1950s. Treatment has improved over the years to its current state‐of‐the art. The aim of the current study was to evaluate the long‐term outcome of haemophilia in terms of incidence, morbidity and mortality. Patients diagnosed with haemophilia A or B registered at the national haemophilia centres and/or the Patient Registry and born before 2009 and alive in 1968 were enrolled and linked to the Cause of Death‐, Migration‐ and Medical Birth registries. Five age‐ and sex‐matched controls were selected for each patient. A total of 1431 patients with haemophilia A or B were compared with 7150 controls. The 3‐year moving average incidence rate per 100 000 population varied between 21 and 36. The hazard ratio for all‐cause mortality compared with controls was 2.2, 95% CI: [1.8; 2.7], P < 0.001 for the entire group of patients and 1.7, 95% CI: [1.3; 2.2], P < 0.001 when patients with HIV and/or viral hepatitis were excluded. The corresponding figures for the severe haemophilia subgroup were 6.6, 95% CI: [4.5; 10.0], P < 0.001 and 8.2, 95% CI [3.2; 20.8], P < 0.001 respectively. The most common causes of death were related to malignancies and the haemostatic defect. People with haemophilia were 57% less likely to die from ischaemic heart disease than controls. People with haemophilia in Sweden demonstrate higher mortality over time, independent of HIV and viral hepatitis, despite relatively advantageous access to clotting factor concentrates.

Bilateral prophylactic mastectomy in Swedish women at high risk of breast cancer: a national survey.

Background/Objective:This study attempted a national inventory of all bilateral prophylactic mastectomies performed in Sweden between 1995 and 2005 in high-risk women without a previous breast malignancy. The primary aim was to investigate the breast cancer incidence after surgery. Secondary aims were to describe the preoperative risk assessment, operation techniques, complications, histopathological findings, and regional differences. Methods:Geneticists, oncologists and surgeons performing prophylactic breast surgery were asked to identify all women eligible for inclusion in their region. The medical records were reviewed in each region and the data were analyzed centrally. The BOADICEA risk assessment model was used to calculate the number of expected/prevented breast cancers during the follow-up period. Results:A total of 223 women operated on in 8 hospitals were identified. During a mean follow-up of 6.6 years, no primary breast cancer was observed compared with 12 expected cases. However, 1 woman succumbed 9 years post mastectomy to widespread adenocarcinoma of uncertain origin. Median age at operation was 40 years. A total of 58% were BRCA1/2 mutation carriers. All but 3 women underwent breast reconstruction, 208 with implants and 12 with autologous tissue. Four small, unifocal, invasive cancers and 4 ductal carcinoma in situ were found in the mastectomy specimens. The incidence of nonbreast related complications was low (3%). Implant loss due to infection/necrosis occurred in 21 women (10%) but a majority received a new implant later. In total, 64% of the women underwent at least 1unanticipated secondary operation. Conclusions:Bilateral prophylactic mastectomy is safe and efficacious in reducing future breast cancer in asymptomatic women at high risk. Unanticipated reoperations are common. Given the small number of patients centralization seems justified.

Associations between unemployment and cardiovascular risk factors varies with the unemployment rate: the Cardiovascular Risk Factor Study in Southern Sweden (CRISS).

Aims: To investigate associations between CVD risk factors and socio-economic status (SES) in middle-age men during a period of economic changes. Methods: Crossectional surveys at age 37, 40 and 43 in a birth cohort of men in Helsingborg, Sweden. All male residents born 1953 - 4 (n=1460) were invited; participation rates were 68% (n=991) at baseline. Of these enrolled, 78% (n=770) were re-examined after three years and 71% (n=702) again after six years follow-up. Main outcome measures were body mass index (BMI), S-cholesterol, HDL-cholesterol, systolic and diastolic blood pressure (SBP, DBP), smoking and leisure time physical activity (LTPA), education, employment, ethnicity. Results: Baseline unemployment rate was low, n=23 (2.4%), but three and six years later it had increased to 61 (8.2%) and 51 (7.5%) respectively. At baseline, BMI and S-cholesterol were significantly higher in unemployed than in employed men (ΔBMI 1.6 kg/m2, CI: 0.2; 2.9, Δ S-cholesterol 0.6 mmol/L, CI: 0.1; 1.0), and in men with short versus long education (Δ BMI 0.9 kg/m2, CI: 0.4; 1.4, Δ S-cholesterol 0.2 mmol/L, CI: 0.03: 0.4), independent of other SES factors. Over the study period crossectional associations with employment status disappeared for BMI, but remained between short education and BMI. Short education was also associated with a significant increase in BMI (Δ=0.4 kg/m2, CI: 0.1; 0.7) during 6-year follow-up. Conclusions: This study shows that associations between unemployment and CVD risk factors were lost when unemployment rates increased. When the attributable risk of unemployment associated with CVD risk factors is estimated, it is vital to consider the general unemployment rates in society.

Comparison of cardiovascular risk factors and survival in patients with ischemic or hemorrhagic stroke.

Background Differences in risk factor profiles between patients with ischemic and hemorrhagic stroke may have an impact on subsequent mortality. Aim To explore cardiovascular disease risk factors, including the CHADS2 score, with survival after ischemic or hemorrhagic stroke. Methods Between 2001 and 2005, 87 111 (83%) ischemic stroke, 12 497 (12%) hemorrhagic stroke, and 5435 (5%) patients with unspecified stroke were identified in the Swedish Stroke Register. Data on gender, age, and cardiovascular disease risk factors were linked to the Swedish Hospital Discharge and Cause of Death Registers. Adjusted odds and hazard ratios and 95% confidence interval were calculated using logistic and Cox proportional hazard regression models. Results Hemorrhagic stroke patients were younger than ischemic stroke patients. All cardiovascular disease risk factors studied, alone or combined in the CHADS2 score, were associated with higher odds ratios for ischemic stroke vs. hemorrhagic stroke. Higher CHADS2 scores and all studied risk factors except hypertension were associated with higher odds ratio for death by ischemic stroke than hemorrhagic stroke. Ischemic stroke was associated with lower early mortality (within 30 days) vs. hemorrhagic stroke (hazard ratio = 0·28, confidence interval 0·27 to 0·29). Conclusions Patients with hemorrhagic stroke had a higher risk of dying within the first 30 days after stroke, but the risk of death was similar in the two groups after one-month. Hypertension was the only cardiovascular disease risk factor associated with an increased mortality rate for hemorrhagic stroke as compared to ischemic stroke.